Retrospective review is the process of determining coverage after treatment has been given. These evaluations occur by:
Retrospective review is available when:
Retrospective review is not available when claims are for:
The retrospective review process includes:
Retrospective review does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider.
For these purposes, “coverage” means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
More stringent state requirements may supersede the requirements of this policy.